Appendix_A_Medical_Auth._form.pdf

DEPARTMENT OF HEALTH & HUMAN SERVICES

NATIONAL HANSEN’S DISEASE PROGRAMS

1770 Physicians Park Drive – Baton Rouge LA 70816

Clinical Branch (225) 756-3701 (225) 756-3706 Fax

Medical Authorization

Patient Name Date of Birth Provider

Service Date Insurance Referring Physician Reason For Visit

The above is a patient at the National Hansen’s Disease Programs (NHDP) and is authorized for treatment.

Please contact the referring physician for approval before referring this patient if medical treatment other than indicated above is necessary.

Send Medical Report to Referring Physician (or return with patient):

National Hansen’s Disease Programs Attn: Mike Peltier 1770 Physicians Park Drive Baton Rouge, LA 70816 225-756-3701

The NHDP cannot pay any payments or a Co-Pay without an invoice being submitted.

Please file patient’s insurance before billing the NHDP for any remaining balance.

Send Itemized Invoice:

National Hansen’s Disease Programs Attn: Marquita Singleton 1770 Physicians Park Drive Baton Rouge, LA 70816 225-756-3744

PLEASE KEEP THIS FORM FOR REPORTING and BILLING INFORMATION.

NHDP Information

Cost Estimate:_____________ Requisition#__________________

NHDP FORM 202 Rev MAY 2016

APPOINTMENT AUTHORIZATION FORM

DEPARTMENT OF HEALTH & HUMAN SERVICES

2929 Loagen Street Baton Rouge, Louisiana 70716